Provider Demographics
NPI:1609470897
Name:CAMPBELL, CARRIE DENISE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DENISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1752
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33882-1752
Mailing Address - Country:US
Mailing Address - Phone:863-226-8553
Mailing Address - Fax:
Practice Address - Street 1:1031 BLACKWOLF RUN RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-7951
Practice Address - Country:US
Practice Address - Phone:863-226-8553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC514-104-76-582-0347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle